Experts in the assessment and treatment of complex mental health disorders

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1 2017 APS COLLEGE OF CLINICAL PSYCHOLOGISTS CONFERENCE Experts in the assessment and treatment of complex mental health disorders Workshop Is it all in my head? Understanding and treating functional neurological disorder Michelle Riashi Friday 30 June am pm #2017Clinical

2 Is it all in my head? Understanding and treating Functional Neurological Disorder Michelle Riashi Senior Clinical Psychologist Dept. of Medical Rehabilitation The St George Hospital 30 June 2017

3 Functional Neurological Disorder Also sometimes known as: Conversion Disorder Psychogenic Psychosomatic Functional Somatoform Abnormal illness behaviour Hysteria

4 Functional Neurological Disorder cases per 100,000 (Powsner & Dufel, 2009) Onset late adolescence to mid 30 s Rare in children < 10 years Women > Men (2:1 to 10:1, Marshall, Landau, Carroll & Schwieters, 2008) High utilisers of health system ( frequent fliers )

5 Prognosis Positive Indicators short duration of sx Early dx + prompt treatment High satisfaction with care Negative Indicators Delayed dx Sx > 1 year duration Personality disorder (Gelauff, Stone, Edwards & Carson 2014)

6 Common Presenting Problems Seizures/blackouts/attacks Paralysis Limb weakness Gait disturbance Poor balance Tremor Dystonia/Spasm Sensory symptoms Pain Fatigue Sleep problems Poor memory/concentration Dizziness Headache/migraine Dysphonia Bladder/bowel symptoms Swallowing problems Twitching/jerking

7 Medically Unexplained Symptoms Medical Speciality Neurology Gastroenterology Rheumatology Orthopaedics Ear, Nose and Throat Infectious Diseases Cardiology Endocrinology Gynaecology MUS Functional Movement Disorder Non- epileptic Seizures Irritable Bowel Syndrome Functional dyspepsia Fibromyalgia Chronic Back Pain Atypical facial pain Chronic unexplained dizziness Functional Dysphonia Globus Pharyngis (post- viral) Chronic Fatigue Syndrome Atypical/Noncardiac Chest Pain Palpitations with normal investigations Borderline Thyroid Function Chronic Pelvic Pain

8 DSM 5 Diagnostic Criteria A. 1 or more symptoms of altered motor and sensory function B. Evidence of incompatibility b/w the symptom and recognised neurological or medical conditions C. Not better explained by another medical or mental disorder D. Causes significant distress/impairment in social, occupational or other important areas of functioning Specify types of Sx or deficits as: With weakness or paralysis With abnormal movement (eg tremor, dystonic mvt, gait disorder) With swallowing Sx With speech Sx (eg. dysphonia, slurred speech) With attacks or seizures With anaesthesia or memory loss With special sensory Sx (eg. visual, olfactory or hearing loss) With mixed Sx Specify if: Acute episode: Sx < 6 months, Persistent: Sx >6 months Specify if: With psychological stressor, Without psychological stressor.

9 Video Diagnosis

10 Misdiagnosis Stone et al 1985

11 Differential Diagnosis Factitious Disorder Conscious Simulation of Sx Unconscious benefit from sick role (interpersonal benefits) Malingering Conscious simulation of Sx Conscious goal in mind (money, time off, attention) Somatic Symptom Disorder Abnormal/maladaptive illness behaviours Excessive thoughts/feelings Not necessarily incompatible with underlying illness

12 Approx 1 in 10 will also have neurological disease present. Comorbidities Rates of psychological comorbidity higher in FND population than in comparable neurologic disorders Depression Anxiety Personality/Cognitive Traits

13 A very brief history lesson 400 BC Hysterikos disease of the womb. Early 17 th century uterus influences brain by sympathetic mechanisms 18 th & 19 th Centuries disorder of function within nervous system. Late 19 th & 20 th Centuries psychologic theories involving dissociation, conversion, intrapsychic conflict, repression and secondary gain dominated. Freud results from the conversion of an unconscious unresolved psychological conflict to somatic representation.

14 Contemporary Theories Attachment Theories Dissociative Models Cognitive-Behavioural Models Neuroscientific Theories Biopsychosocial Model

15 Attachment theories Attachment disruptions Safer communication of emotion, needs and wants The Unspeakable Dilemma

16 Dissociative theories PNES and detachment Depersonalisation and Derealisation Role of Compartmentalisation in FND the reversible loss of voluntary control over apparently intact processes and functions

17 CBT model

18 Neuroimaging

19 Feinstein. A. (2011) Conversion Disorder: Advances in our understanding. CMAJ. 183 (17),

20 Neuroscientific Findings Neurophysiologic tests demonstrate normal functioning of primary motor and sensory areas. Neuroimaging suggests increased activation in limbic system (responsible for regulation and expression of emotion) and increased connectivity to motor and sensory systems. Abnormality in premotor cortex (responsible for the planning, control and execution of voluntary movements) Decreased or abnormal activation of corresponding sensory and/or motor cortices.

21 Biopsychosocial Model of FND Image: Stonnington, Barry, & Fisher, (2006) Conversion Disorder Am J Psychiatry 163:9,

22 Predisposing Factors Genetic Factors Neurological vulnerabilities in the central nervous system Attachment disruption Childhood neglect/abuse Poor family functioning Symptom modelling by others History of previous functional symptoms

23 Precipitating Factors Abnormal physiological state or event (eg hyperventilation, sleep deprivation) Physical injury/pain Illness Perception of the event as negative/unexpected/dangerous Acute dissociative episode/panic attack Stressful life event

24 Perpetuating factors Neuroplasticity Deconditioning Illness beliefs Perception of symptoms as being due to disease/damage/outside the scope of self-help Not feeling believed Avoidance of symptom provocation Social/financial benefits of being ill Stigma of mental illness in society and medical professionals Ongoing medical investigations and uncertainty

25 Case Study

26 Assessment Aim to: Identify any problems associated with physical symptoms, Identify any factors that may be maintaining symptoms, and Identify what factors need to be addressed in therapy to allow recovery and minimise relapse.

27 Assessment Need to confirm diagnosis/investigations (Are they complete? Was the pt given a dx?) Level of confidence in, or openness to, FND dx. List of physical symptoms and history When were you last really well, without any of these symptoms? Time line mapping sx and severity, along with medical investigations/interventions, as well as life events.

28 Assessment Patient s illness beliefs the cause and consequences of symptoms, how long the symptoms will last, as well as what may make symptoms better or worse. Avoidance Safety behaviours Impact on relationships

29 Assessment Dissociation ask about depersonalisation and derealisation, gaps in memory, distortions in time. Alexithymia Mood depression, anxiety, anger Family history Recent and childhood stress

30 Assessment Tools Useful assessment measures DASS/BDI/BAI Toronto Alexithymia Scale Emotion Control Questionnaire 2 ACE questionnaire (used informally in clinical interview) Dissociative Experiences Scale Use of pain or body maps Symptom diary

31 Toronto Alexithymia Scale 20 items 3 subscales difficulty describing feelings, diffiuclty identifying feelings and externally-oriented thinking Scoring < 51 = non-alexithymia 52 > 60 = possible alexithymia > 61 = Alexithymia

32 ECQ2 Examines tendency to inhibit the expression of emotional repsonses. 4 subscales Rehearsal, Emotional inhibition, Aggression control Benign control

33 ACE Questionnaire Adverse Childhood Experiences Study 17,421 individuals screened for: Household dysfunction (substance abuse, parental separation/divorce, mental illness, domestic violence, criminal behaviour) Abuse (psychological, physical, sexual) Neglect (Emotional/Physical) Authors were Vincent Felitti and Robert Anda

34 ACE study ACE SCORE Prevalence 0 35% 1 26% 2 16% 3 10% 4 or more 16%

35 ACE Study Demonstrated adverse childhood experiences are common Strong predictors of mental and physical health risks and disease from adolescence to adulthood

36 Dissociative Experiences Scale 28 item self-report, Screening measure for dissociation Cut-off score: >30 Authors: Bernstein and Putnam

37 Body Map

38 Challenges to assessment Misdiagnosis in past May be mistrustful or resentful of psych referral especially if accused of faking or exaggerating in the past May under-report psych sx May over-report physical sx

39 Treatment Consultancy Explanation as treatment Bottom-up Top-down Address any comorbidities

40 Advocate for positive diagnosis Explanation of diagnosis should: Take the problem seriously Make it clear that there is a diagnosis Demonstrate the rationale for the diagnosis Convey the potential for reversibility This is a familiar and genuine problem, you have what is known as functional neurological disorder. This means that your symptoms are because of dysfunction in the nervous system, not damage to the nervous system. This is why your investigations may look normal but you are still experiencing problems, your hardware is good but there is a problem with the software. While frustrating, the good news is that because the nervous system is not damaged, your symptoms should be reversible with treatment.

41 General Treatment Principles Coordinated and multidisciplinary approach to care Remember the 3 R s real, recognisable and reversible. Create an expectation of improvement but avoid the double bind Limit unnecessary investigations and procedures Agree on a monitoring plan Schedule regular medical/ah reviews.

42 Guidelines for physical therapies Therapy should be goal-directed. Foster independence and self-management. Limit hands-on treatment when handling patient, facilitate rather than support. Encourage early weight-bearing. Focus on function and automatic movements (eg walking), rather than impairment (eg weakness) and controlled (attention-full) movement (eg strengthening exercises) Minimise reinforcement of maladaptive movement patterns and postures

43 Guidelines for physical therapies Retrain movement utilising diverted attention. Avoid adaptive equipment and mobility aids where possible Need to balance this with independence and fx. Avoid the use of splints and devices that immobilise joints Develop a relapse prevention plan that fosters self-management.

44 Explanation as treatment Present case formulation + rationale for treatment components Psycho-education re mind-body relationship Body Outline (participant exercise explanation and rationale)

45 Bottom-Up Breathing exercises HRV breathing and MyCalmBeat app Sleep Hygiene Hydration Nutrition Relaxation Training Mindfulness Training

46 Behaviour Change Behavioural activation Pleasant activity scheduling Principles of pacing Target reduced and avoided activities Behavioural experiments (CBT) Value-driven action (ACT)

47 Top-Down Noticing and challenging unhelpful thoughts/beliefs (CBT) Defusion skills and Values identification (ACT) Identifying, naming and understanding emotions (in self and others) (DBT)

48 Treatment Affect regulation Model healthier interpersonal/attachment style Address any co-morbid psychological issues Depression Panic Anxiety

49 Discourage ambulance/medical attention when dissociative seizure occurs Distraction and re-focusing techniques Applied relaxation and breathing techniques training Practice implementing when experience seizure warning signs. Graded exposure to avoided situations or activities Cognitive restructuring PNES Identification and challenging of malapdaptive thinking styles, negative views of future/self, unhelpful thoughts/beliefs about seizures. Relapse Prevention

50 Treatment Challenges Team consistency in approach Resistance to need for psychological input Dealing with anger or excessive praise Emerging emotional dysregulation

51 Case Study

52 Importance of Self Care Professional burn-out Helplessness, over- idealised or under-valued, collegial, patient and self - expectations to fix it. Importance of practicing self-awareness/self-care Supervision Examine self-expectations as a therapist Exercise, sleep hygiene, relaxation/mindfulness, self-talk/values.

53 Resources Useful Websites

54 Resources Reading List Goldstein LH, LaFrance Jr WC, Chigwedere C, Mellers JDC, Chalder T. Cognitive behavioral treatments. In: Schachter SC, LaFrance Jr WC, eds. Gates and Rowan s Non-Epileptic Seizures, 3rd ed. New York: Cambridge University Press;; 2010: Hallett, M., Stone, J & Carson, A. (2016) Handbook of clinical neurology: Functional Neurologic disorders, 139. Nielsen G, et al. J (2014) Physiotherapy for functional motor disorders: a consensus recommendation, Neurol Neurosurg Psychiatry, 1 7. Stone, J. (2009) The bare essentials: Functional symptoms in Neurology. Pract Neurol 9: Van der Kolk, B. (2014) The body keeps the score: Mind, brain and body in the transformation of trauma. Allen Lane. Williams, C., Kent, C., Smith, S., Carson, A., Sharpe, M. & Cavanagh, J. (2011) Overcoming functional neurological symptoms: a five areas approach. Hodder Arnold

Aetiology of medically unexplained neurological symptoms

Aetiology of medically unexplained neurological symptoms Richard J. Brown PhD, ClinPsyD University of Manchester, UK Manchester Mental Health and Social Care NHS Trust Overview 1. Are symptoms simply made